Provider Demographics
NPI:1083754477
Name:CW ODELL CHIROPRACTIC CLINIC
Entity Type:Organization
Organization Name:CW ODELL CHIROPRACTIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CLAIR
Authorized Official - Middle Name:W
Authorized Official - Last Name:ODELL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:734-284-2828
Mailing Address - Street 1:14390 FORT ST
Mailing Address - Street 2:
Mailing Address - City:SOUTHGATE
Mailing Address - State:MI
Mailing Address - Zip Code:48195-1271
Mailing Address - Country:US
Mailing Address - Phone:734-824-2828
Mailing Address - Fax:734-284-0322
Practice Address - Street 1:14390 FORT ST
Practice Address - Street 2:
Practice Address - City:SOUTHGATE
Practice Address - State:MI
Practice Address - Zip Code:48195-1271
Practice Address - Country:US
Practice Address - Phone:734-824-2828
Practice Address - Fax:734-284-0322
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301000765111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MICOBMQMedicare UPIN